The RN Care Manager is a registered nurse who is an integral part of the primary care practice team and is responsible for organizing, coordinating, and providing care coordination and care management services to complex medical patients. The RN Care Manager works collaboratively to ensure that the care team maintains a central role in managing and delivering effective and efficient patient and family centered care, including acute illness management, chronic disease management, and preventive care, achieving high quality, cost effective outcomes across the continuum of health care.
Duties & Responsibilities:
Provide comprehensive care management focused on improving health outcomes of complex medical patients, including the creation, documentation, execution and maintenance of a person-centered plan of care. Activities included in the delivery of Comprehensive Care Management services include, but are not limited to, the following:
Conduct an in-person comprehensive biopsychosocial needs assessment to collect behavioral, primary, acute and long-term care information from all health and social service providers appropriate for a particular patient, and determine level of acuity based on severity of disease, self-care capacity , family support, socioeconomic factors, poly-pharmacy, and health care utilization trends;
Identify the patient's and family's physical, psychosocial, environmental, safety and developmental needs.
Develop a person-centered plan of care that identifies patients’ strengths and preferences related to health and social services, is congruent with patients’ needs, and focus improving clinical and patient-centered outcomes.
Delegate appropriate tasks in accordance with the Plan of Care to members of the team
Update/ reevaluate the person-centered plan of care in the certified EHR system in accordance with funding and regulatory requirements
Monitor the patient’s health status and document the patient’s progress
Communicate/affirm patient needs, plan of care, and change in status with the PCC, team and the patient/family
Coordinate transitions between healthcare providers and settings to reduce hospital emergency department and inpatient admissions, readmissions and length of stay.
Conduct quality improvement and population health management activities as assigned by supervisor , including but not limited to:
Participate monthly on the Quality Committee and assist in the development of nursing indicators to assure ongoing monitoring and evaluation of existing processes
Implementing nursing-evidence based practice by identify issues related to quality indicators
Implement effective, population-based nursing intervention across the health care continuum to improve patient’s health outcomes
Provide leadership to the care teams by working collectively to improve the outcomes through the utilization of population health data and reporting systems
Analyze processes and promote change in a team environment
Lead interdisciplinary meetings to review and discuss patient outcomes.
Review progress towards meeting key health outcome goals, and lead care team in developing strategies to meet or improve goals for program as a whole.
Proactively participate in education in order to provide quality care and improve professional skills
Provide general nursing care with medical services team as assigned by supervisor, including:
In collaboration with the care team and patient/family, provide basic nursing education focused on self-care appropriate to patient age and identified learning considerations and needs
Utilize evidence-based nursing interventions during patient care, with an emphasis on Patient Centered Medical Home
Utilize telehealth nursing services to assist patients in making informed decisions regarding access to care, monitor patients’ conditions, and manage care for both acute and chronic illnesses
Provide population- and age appropriate care in a culturally appropriate, caring, compassionate, ethnically sensitive manner.
Conduct in-person and telephone triage with patients to determine need and appropriateness for visit, coordinating with providers as needed and timely documentation in the medical record
Assist provider with examination and procedures as assigned.
Provide a safe environment and promotes quality patient care through adherence to established standards at the facility.
Comply with all required administrative and programmatic requirements of the position, including but not limited to:
Follow all protocols and procedures required by funders and by La Clínica del Pueblo regarding care management duties and responsibilities
Demonstrate professional, appropriate, effective, and tactful communication skills, including written, verbal and nonverbal
Demonstrate a positive attitude and respectful, professional customer service
Acknowledge patient’s rights on confidentiality issues, maintains patient confidentiality at all times, and follows HIPAA guidelines and regulations
Proactively act as patient advocate, responding with empathy and respect to resolve patient and family concerns, and recognize opportunities for improvement to meeting patient concerns
Maintain medical records including completeness, filing, neatness, confidentiality, and documentation.
Attend required internal and external program meetings and trainings.
Complete monthly reports as assigned
Meet with supervisor as required.
Provide other activities as identified by your supervisor.
Currently licensed as a Registered Nurse in the District of Columbia (or Maryland if position is in Hyattsville Clinic), required
Current BLS Certification, required
Fluent written and spoken Spanish-English, required
Three years prior experience working in community health or patient care settings, prior population/care management experience preferred
Baccalaureate degree in nursing (BSN), preferred
One year prior experience working with Latino/ underserved communities preferred
One year prior HIV experience, preferred
Care Coordination and Transition Management training and board certification (CCTM) preferred.
Strong critical thinking and analytic skills
Excellent skills in nursing assessment and development of plan of care
Ability to prioritize and make independent clinical judgments
Ability to effectively evaluate care across the continuum care
Ability to work collaboratively and cooperatively within an interdisciplinary team.
Effective verbal and written communication skills.
Proficiency in MS Office, including word, excel, and PowerPoint
Experience using Electronic Health Record/ Practice Management software; eClinicalWorks (ecW) preferred
About La Clinica Del Pueblo, Inc.
La Clinica del Pueblo is a non-profit, federally qualified health center that serves the Latino and immigrant populations of the Washington, DC metro area. La Clinica del Pueblo is comprised of 5 sites in Washington, DC and Prince George's County, MD. Our mission is to build a healthy Latino community through culturally appropriate health services, focusing on those most in need.
-Mental Health & Substance Abuse Services
-Community Health Action